1962991703 NPI number — SOUTHERN HEALTHCARE ALLIANCE, LLC

Table of content: (NPI 1962991703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962991703 NPI number — SOUTHERN HEALTHCARE ALLIANCE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN HEALTHCARE ALLIANCE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962991703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101-F W. NORTHSIDE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-262-1981
Provider Business Mailing Address Fax Number:
229-375-0392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101-F W. NORTHSIDE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-262-1981
Provider Business Practice Location Address Fax Number:
229-375-0392
Provider Enumeration Date:
05/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SWADER
Authorized Official First Name:
SHERI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
229-262-1981

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003208546C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003229819A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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